Client Consultation Form – Skin Care & Eye Treatments and
Facial Electrical Treatments
2011 version 4.1
College Name:
The National School of Aesthetics
College Number: 1485
Student Name:
Student Number:
Date:
01/01/2010
Client Name:
Address:
Profession:
Tel. No:
PERSONAL DETAILS
Age group:
Under 20
20—30
30—40
Lifestyle:
Active
Sedentary
Last visit to the doctor:
01/01/2010
GP’s Name:
GP Address:
No. of children: (if applicable)
Date of last period: (if applicable)
01/01/2010
Day:
(03) 123-4567
Night: (03) 123-4567
40—50
50—60
60+
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION
In circumstances where medical permission cannot be obtained, clients must give their
informed consent in writing prior to treatment.
Select if/where appropriate:
Recent operations
Diabetes
Nervous/psychotic conditions
Undiagnosed pain
Epilepsy
Taking prescribed medication
Medical oedema
Skin cancer
Whiplash
Slipped disc
Pregnancy
Haemophilia
Cardiovascular conditions1
Acute rheumatism
Bells Palsy
Any dysfunction of the nervous system2
Any condition already being treated by a GP or another practitioner
Trapped/pinched nerve
Inflamed nerve
Osteoporosis
Spastic conditions
Kidney infections
Asthma
CONTRAINDICATIONS THAT RESTRICT TREATMENT
Select if/where appropriate:
Hormonal implants
Fever
Sinusitis
Contagious or infectious diseases
Diarrhoea and vomiting
Under the influence of recreational drugs or alcohol
Hypersensitive skin
Recent fractures (minimum 3 months)
Localised swelling
Undiagnosed lumps and bumps
Inflammation
Botox/dermal fillers (1 week following treatment)
Cuts
Bruises
Abrasions
Sunburn
Neuralgia
Any known allergies
Migraine/Headache
Eczema
Hyper-keratosis
Skin allergies
Styes
Watery eyes
Inflamed nerve
Scar tissues (2 years for major operation, 6 months for a small scar)
Trapped/pinched nerve affecting treatment area
Eye infection
Conjunctivitis
Haematoma
Skin diseases
Cervical spondylitis
Any metal pins or plates
Loss of skin sensation (test with tactile test)
1
2
Including, but not limited to, thrombosis, phlebitis, hypertension, hypotension and heart conditions
Including, but not limited to, Muscular Sclerosis (MS), Parkinson’s Disease and Motor Neurone Disease
SKIN TEST
Select if/where appropriate:
Moisture content:
Excellent
Good
Muscle tone:
Excellent
Good
Elasticity:
Excellent
Good
Sensitivity:
High
Medium
Skin’s healing ability: Excellent
Good
Skin tone: (Fitzpatrick) Fair
Medium
Circulation:
Good
Normal
Pores:
Fine
Dilated
Fair
Fair
Fair
Low
Fair
Dark
Poor
Comodones
Poor
Poor
Poor
Poor
Olive
Milia
Overall Skin Type:
Treatment to include
Select if/where appropriate:
Manual Facial Treatments
Superficial Cleanse
Pre-heat Treatment
Skin Analysis
Brow Tinting
Eyebrow Tweezing
Mask
Facial Electrical Treatments
Iontophoresis
Vacuum Suction
Direct High Frequency
Microcurrent
Desincrustation
Faradism
Indirect High Frequency
Deep Cleanse
Massage
Lash Tinting
Skin Care & Eye Treatments and Facial Electrical Treatments Case Study Form 2011 v 4.1
2
Treatment details (including products used):
Client feedback:
After care/Home care advice:
Therapist’s/student’s signature:……………………………………………………………………
Client’s signature:…………………………………………………………………………………….
Skin Care & Eye Treatments and Facial Electrical Treatments Case Study Form 2011 v 4.1
3